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Improving Emergency Department Triage with POCT

As the number of Americans visiting emergency departments (ED) has grown, so have wait times, making crowded EDs a significant patient safety issue for many hospitals. A recent study, explored in this issue of Strategies, found that point-of-care testing in the hands of ED nurses can change management in a significant number of patients.

Wait times in EDs have experienced at least a decade-long rise, as the number of ED visits has outpaced population growth by significant margins, according to the U.S. Centers for Disease Control and Prevention National Center for Health Statistics . In CDC’s most recent data looking at 2003 through 2009, the mean wait time in EDs increased 25%, from 46.5 minutes to 58.1 minutes. This follows a rise in overall ED visits from 1999 through 2009, when the number of visits to EDs increased 32%—from 102.8 million in 1999 to 136.1 million in 2009. In some hospitals, increased ED volume has resulted in increased wait times for even serious problems, such as myocardial infarction, according to CDC.

As ED crowding has become more common, triage has taken on added importance, and hospitals have experimented with a variety of strategies to streamline the process and make it safer. Seeking to improve triage in the context of lengthening wait times, researchers from the University of Pennsylvania Health System in Philadelphia investigated whether rapid, point-of-care testing (POCT) could improve triage (Am J Emerg Med October 2012. doi 10.1016/j.ajem.2012.07.025).

Olanrewaju Soremekun, MD, MBA, and his colleagues conducted the pilot study at the Hospital of the University of Pennsylvania, a busy urban hospital with some 60,000 annual visits. They found that POCT led to a change in management in 15% of patients, with 6% being brought back for rapid physician evaluation. More than half of patients had at least one abnormal lab result in the POCT protocol.

The researchers enrolled 300 patients over a 12-month period who had been triaged to the ED waiting room with high-risk complaints, such as chest pain or shortness of breath in those older than 40, possible infection based on vital signs, and those older than 65 with non-traumatic complaints. A nurse in the ED conducted POCT using a hand-held Abbott i-STAT device, selecting tests based on patients’ complaints. The POC assays included troponin, hemoglobin, B-type natriuretic peptide, and lactate; as well as a metabolic panel of sodium, potassium, chloride, total carbon dioxide, ionized calcium, glucose, urea nitrogen, creatinine, and hematocrit.

The researchers tracked patient demographics as well as comorbid conditions, Emergency Severity Index (ESI) triage level, and ED census at time of enrollment. They also conducted a survey of triage nurses who received POC results that queried the overall helpfulness of the results, and any changes in levels of clinical concern, ESI level, or clinical management.

Nurses found POCT to be helpful in more than half of patients, 56%, a factor Soremekun attributes to the testing having given the nurses more confidence in their triage decisions. “I think the point-of-care test reassures the triage nurse that decisions they made are appropriate,” he said. “There is often a lot of uncertainty around whether they triaged a patient correctly, and rapid point-of-care tests can confirm their decisions.” Soremekun is also an assistant professor in the department of emergency medicine at the University of Pennsylvania.

Even more significant were those tests that led to a changed ESI acuity level. In 4% of patients, the acuity level increased, while 10% were triaged to lower acuity level. The slant toward lower acuity levels after triage was not a big surprise, according to Soremekun. “We expect triage to be as sensitive as possible, so generally we would rather over-call and have a patient seen a little sooner than necessary, than under-call,” he said. “Triage nurses tend to err on the side of caution, and if there is any doubt, triage a patient to a higher acuity when possible.”

With POCT enabling triage nurses to confidently select a lower acuity for some patients, these tests could be especially helpful if deployed when the ED is crowded, according to the researchers. “In these situations, it could actually be more helpful in identifying the patients who can wait rather than those who can’t, which is supported by our results where more than [three] times as many patients had their triage levels downgraded as upgraded,” they wrote.

The study also shows that a relatively high-risk group of patients is routinely triaged to wait, the researchers noted. They found that 6% of troponin results, 3% of hemoglobin results, 6% of potassium results, and 5% of lactate results were abnormal. The most common abnormal results were B-type natriuretic peptide and anion gaps.

Adding POCT to triage in the ED follows a trend of enhancing triage and intake processes in order to cope with higher volumes and longer wait times, noted Michael Drescher, MD, associate chief of the division of emergency medicine at Hartford Hospital in Hartford, Conn. “There is already some precedent for this as many EDs work to speed the turnaround of lab results, including ordering labs earlier in the process by someone who does not have the benefit of the full history and physical examination of the patient,” he said. “That is now well-accepted. As our throughput processes in the ED get bogged down with overcrowding, we’re moving more of these processes toward the input side, our triage and intake areas.” Drescher was not associated with the study.

Nevertheless, ED physicians and labs need to think through what some of the unintended consequences of wider POCT testing could be, Drescher cautioned. For example, the POCT process takes more time and effort on the part of nurses. “This is a very valuable line of inquiry, but we need to learn more,” he said. “When the ED is very busy, everyone’s time is at a premium, and performing that test is adding an extra step to the triage process, so you could actually end up slowing things down from that perspective. You’re trying to improve the process, but you’re also making the process more complicated.”

A less selective approach to testing would also bring with it more false positives, Drescher noted. “It’s inevitable that you’ll do further tests or procedures you might not have otherwise done,” he said. “It’s hard to know what price you will pay at the end of the day in terms of over-testing.”

One of the most important findings of the study is the number of cases in which POCT results prompted expedited care, researchers emphasized. Put another way, the 6% of patients for whom rapid physician evaluation was called represents approximately 1 in 20 patients. From this perspective, POCT at triage could help EDs avoid missing a significant number of patients who need more urgent care than nurses would otherwise realize.